The documents included with this facsimile transmittal contain information from Fresenius Medical Care North America that is confidential and/or privileged. This information is intended to be for the use of the addressee named on this transmittal sheet. If you are not the addressee, note that any disclosure, photocopying, distribution or use of the contents of this faxed information is prohibited. Velphoro is a registered trademark of Vifor Fresenius Medical Care Renal Pharma Ltd. Distributed by: Fresenius Medical Care North America, Waltham MA 02451 © 2021 Fresenius Medical Care. All Rights Reserved. Printed in USA PN 103575-02 Rev. B 04/2021

Section 1: Patient Information First Name: Last Name: SSN:

Street Address: (NO P.O. BOXES, product will be shipped to patient’s home) DOB: (Patient must be 18 yrs or older)

City: State: Zip: Phone:

Are you currently on dialysis? ! Yes ! No Gender: ! Male ! Female

Is this a Fresenius Kidney Care patient? ! Yes ! No

Section 2: Patient Insurance Information

Please select insurance type: ! Commercial ! Medicare Part: _______ ! Medicaid ! VA/Military Benefits ! Other: _________________________________ ! None

Medical Insurance Company Name: Please provide a copy of the patient’s insurance card if available

Member ID #: Phone Number:

Policy Holder Name: Group #: BIN #:

Prescription Drug Coverage Company Name: Please provide a copy of the patient’s insurance card if available

Member ID #: Phone Number:

Policy Holder Name: Group #: BIN #: PCN #:

Section 3: Prescriber and Dialysis Facility Information Prescriber Name: Dialysis Facility Name:

Practice Address: Dialysis Facility Address:

City: State: ZIP: City: State: ZIP:

MD Office Contact Name: Dialysis Facility Contact Name:

Phone: Fax: Phone: Fax:

MD Office Contact Email: Dialysis Facility Contact Email:

Prescriber State License #: Expiration Date: Prescriber NPI #: Prescriber TAX ID:

Section 4: Phosphate Binder Treatment Information If it is determined that a Prior Authorization is needed, Velphoro Access Solutions may initiate a Prior Authorization on your behalf.

Diagnosis Code (ICD-10): ! E83.39 ! E83.30 ! N18.6 ! N25.0 ! Other ___ Velphoro Daily Dosing: _____ Tablets

Current Calcium Lab Values:

Date: _________ Value:______mg/dL

Current Phosphorus Lab Values:

Date: _________ Value:______mg/dL

Current Ferritin Lab Values:

Date: ______ Value: ______

Current TSAT Lab Values:

Date: _____ Value: ______

Previous Therapy: ! Sevelamer carbonate ! Calcium acetate tablets ! Velphoro ! Sevelamer hydrochloride

! Calcium acetate oral solution ! Lanthanum carbonate ! Calcium carbonate ! Ferric citrate

Additional Information:

Section 5: Authorization by HCP or Patient FOR THE HCP: My signature below certifies that the person named on this application is a patient of this medical practice or dialysis clinic, as applicable, and is under the supervision of a physician or other healthcare professional. I understand the Velphoro Access Solutions program must have authorization to conduct a benefit verification and insurance research. By providing authorization, I permit RxCrossroads by McKesson, Fresenius Medical Care North America’s contractor, to contact the insurer(s), including Medicare, about Velphoro treatment, and allows the insurer(s) to disclose the relevant information about the patient.

FOR THE PATIENT: My signature below certifies that I am a patient of this medical practice or dialysis clinic, as applicable, and am under the supervision of a physician or other healthcare professional. I understand the Velphoro Access Solutions program must have authorization to conduct a benefit verification and insurance research. By providing authorization, I permit RxCrossroads by McKesson, Fresenius Medical Care North America’s contractor, to contact my insurer(s), including Medicare, about Velphoro treatment, and allows the insurer(s) to disclose the relevant information._________________________________________________ __________________________________________________ HCP Title (please print) Name of Practice/Dialysis Clinic _________________________________________________ ___________________________________ HCP or Patient Signature Date

Is this a Renewal Benefit Investigation: !Yes ! No

Velphoro Access Solutions Application for Benefit Investigation Services Please Fax Completed Application to: 1-866-496-8638

All applications are valid for twelve months from the HCP or Patient signature date or until December 31st, whichever comes first. Please make a copy of this application for your records. Program Phone Number: 1-877-774-6756

The documents included with this facsimile transmittal contain information from Fresenius Medical Care North America that is confidential and/or privileged. This information is intended to be for the use of the addressee named on this transmittal sheet. If you are not the addressee, note that any disclosure, photocopying, distribution or use of the contents of this faxed information is prohibited. Velphoro is a registered trademark of Vifor Fresenius Medical Care Renal Pharma Ltd. Distributed by: Fresenius Medical Care North America, Waltham MA 02451 © 2021 Fresenius Medical Care. All Rights Reserved. Printed in USA PN 103575-02 Rev. B 04/2021

Velphoro Access Solutions will perform a benefit investigation and provide the patient’s prescription insurance benefit to the dialysis facility and the physician’s office, as well as provide pharmacy information as applicable. The patient’s pharmacy will supply the product.

1. Fill out the application. To prevent processing delays, please complete all fields legibly in each section. This willassist with expediting and processing of the application. Fill out sections 1-4, and sign section 5.

2. Please attach legible copies (front and back) of the patient’s pharmacy (PBM) insurance card(s) and medical facesheet. Make copies of both sides of the insurance card and prescription drug card large enough so that all theinformation is readable (especially ID number, contact phone number and address).

3. Fax the completed application to Velphoro Access Solutions at 1-866-496-8638.

4. Case managers are available to answer questions between 8AM to 8PM ET at 1-877-774-6756.

Section 1: Patient Information • The patient’s information is required

Section 2: Patient Insurance Information

• This section allows your Velphoro Access Solutions case manager toexplore all potential coverage options, including both primary andsecondary pharmacy/PBM insurance

• Include all sources of medical and prescription coverage, includingcommercial, Medicare and Medicaid (if applicable)

• Member ID should include commercial, Medicare Part D, or Medicaid

Section 3: Prescriber Information

• Insurance companies require this information to provide benefitverification

• Please indicate the provider NPI, DEA, and State License numbers

Section 4: Prescription Information

• Be sure to check the correct lab values, dosing of Velphoro, as wellas any prior therapies taken for benefit verification

Section 5: Benefit Verification Authorization

• Sign the application. The Velphoro Access Solutions Applicationcannot be processed without signature from the HCP or patient (orpatient’s authorized representative).

Velphoro Access Solutions Benefit Investigation Application

Instruction Guide

Velphoro Access Solutions Application for Benefit Investigation Services Please Fax Completed Application to: 1-866-496-8638